Since inception, expectation that the National Health Insurance Scheme (NHIS) will reduce the burden of health care financing has remained on the front burner amid minimal impact of the scheme. In this interview with Paul Obi, NHIS Acting Executive Secretary, Mr Femi Akingbade, speaks on the current strategy for more optimum results in health insurance

The NHIS scheme has been in existence for more than a decade and Nigerians have not had that much impact, so what is the level of coverage?

The level of coverage is still very low for now, in all fairness we just serve about 5 to 6 per cent of the total number of Nigerians registered for one form of insurance or the other. Either through the social health insurance plan organised by the federal government or the private plans which the HMOs are anchoring. The total figure that we have is still less than 10 per cent.

What do you think has been the biggest challenge confronting the expansion of the scheme both in scope and reach?

I want to assume that the main thing that has actually hindered the scheme is the non-mandatory nature of health insurance in Nigeria. You actually see that the constitution on health makes health to be on the concurrent list which means that the three tiers of government are not bounded by the same law. The federal government can promulgate a law and the state government can have their own law in the state while even in the state, the local governments can have their own law too so that the non-mandatory nature is not allowing people to be forced into health insurance or it to be mandatory for them to be under one scheme or the other.

Secondly the wrong misconception of insurance, in our course of advocacy to different state and locations, you will find out that religious beliefs also prevent people from wanting to join the health insurance because a lot of people presume that once you say insurance cover, that means you are predicting bad things to happen to you.

The moment you mention the word insurance people say God forbid I am not going to be sick! What we tell people is that it is not about sickness; pregnancy is not a sickness it is a thing of joy and something one prepares for but on the day you want to deliver per adventure you are asked to carry out a cesarean section and you have to pay out of your pocket, the amount you will pay out of your pocket is quite much more than what you would have paid if you had joined a prepaid scheme and these are the things that are mitigating against the rapid expansion.

If you look at the coverage, you will agree that even within government, it is still at the peripheral level, the informal sector is completely left out. What strategies are there to penetrate the informal sector?

That will not be at the government’s level because for the government’s level it is the formal social health insurance scheme that we are running and if the level of coverage especially within the federal government workers, it is almost super saturated I am sure we can boast of about 95 per cent coverage within the federal civil service.

But when you get to the states, the non-mandatory nature is still barring a lot of people from registering. If you are talking about the informal sector, you need to be able to identify the strata in the informal sector. There are some people in the informal sector that can be identified as poor, vulnerable, socially excluded because of disability, incarceration and some things like that, definitely they cannot afford to pay. And there are some people in the informal sector, they are semi -employed, they have a means of income and they can pay but because it is not mandatory for them to join, there is a problem in them keying into the scheme so one of the things we need to start to look at is how to segregate this, identify those that cannot pay so that government can know their responsibility.

For those in the informal sector that cannot pay are enormous and for those that can afford to pay in the informal sector, how do we group them together to be able to make them make some contributions into the general pool? Because the whole idea of insurance is to be able to gather a pool of funds and to be able to distribute it equitably to buy services at health care facilities for the people to enjoy. We are looking at the informal sector, we have tried the community-based insurance programme that is taking health insurance to the communities by forming mutual health associations and within those mutual health associations we have a board of trustees that purchases health for these people.

Of recent, people have expressed concern about the challenges the national health insurance scheme will have with regards to the TSA, what are the modalities in place to avoid these hiccups and obstacles that may likely come up?

I think the biggest obstacle that is likely to show its face concerning the TSA will be access to the funds that we currently have. It is a contributive scheme and the whole idea is to be able to have a pool of funds and if this pool of funds is not made easily accessible for us to be able to finance gaps where there are gaps then there is going to be a problem. For now running from the TSA is not really much of a problem but we have built a level of funds over time which is supposed to be a subsidy gap fund and these funds are based on the administrative charges and other charges that we have taken over time and invested and this money has grown. So, if government takes it away and we don’t have a buffer fund then it could actually be a threat to the existence of health insurance in Nigeria.

You’ve highlighted that government is in collaboration with development banks to create access through the establishment of about 10,000 health centres covering all the political wards across the country. What is the synergy that is going to drive its progress?

This is the health reform agenda, which is being pioneered also by the minister of health. The 10,000 facilities are going to be public facilities but we know that these 10,000 public facilities will not be adequate to take care of the surging crowd that will come when the health insurance is working. Because with development of 10,000 primary health care centres across the country in each political ward, we are looking at a minimum of one hundred million (100,000,000) people to be under this health insurance cover. 10,000 facilities will not be able to take care of everybody in these locations and what we are saying is that outside of this 10,000 facilities we also want to complement it by involvement of the private sector. Because we can’t rely solely on public facilities, public health officials.

We need to also involve the private sector. Some of them have invested in hospitals in some of these locations, some of them are willing to invest in facilities in some other locations, some of them are people that either due to age or longevity in service they have retired but they are still not tired. They are still interested in taking part and that is why we are saying we are already in discussion with development partners, with donor partners that can come in with funds, make these funds available to these people in the private sector to give them at a single digit and then be able to run it.

There are also cases of abuse perpetrated by the health maintenance organisations. What are you doing to curtail such abuses and ensure that they adhere strictly to the laws?

We have the healthcare facilities; we have the health maintenance organisations even NHIS is there on its own. The disparity and the anomalies cut across all the strata of stakeholders, we have had reports that some healthcare facilities also turn down NHIS patients. By the time you get there they tell you they don’t have drugs and yet they refer you to the nearby pharmacy and things like that.

So such practices are not only limited within the health maintenance organisations. Yes we have had cases in recent times of some health maintenance organisations being reported for breach of agreement and NHIS has come out and taken adequate steps either to sanction, to suspend or outright warnings to them.

This is a growing concern for us in National Health Insurance Scheme , we think that quality of service drives the demand because when the people are not satisfied with the services they are getting, a lot of people will not want to come again. So for us, it is going to be a continuous thing. We will make sure at every point in time that the enrolee is always king and that is why we organised a stakeholder forum last week for all the stakeholders to be aware of the moves that are coming up.

What are you doing to encourage acceptance of NHIS as a platform for everybody?

One of the things that government can do to help this country is to first and foremost find a way to make it mandatory for everybody in this country to be under one form of insurance or the other. And then we at NHIS will be able to develop a pro-poor scheme because we have a large population of people under this category which is classified as pro- poor.

We should be able to develop schemes that will cover this pro-poor from the pool of funds that is gathered. Involvement of the private sector is something that is paramount, government cannot do everything alone right from funding to establishment of hospital to institutionalising quality service.

It is something that we need the involvement of the private sector and for us in NHIS we have been advocating to the states for each of the states to also take it up even at that state level to create agencies that will manage the health of its people. We cannot run everything from the centre and until the states start to see reason on what we are saying, it might still be difficult for us to get to the grassroots.

Because getting to the grassroots we need to pass the state governments, we need to pass the local government authorities to be able to get to those people at the grassroots. We cannot stay here in the centre in Abuja and expect that we are going to pay the staff salary of the people that are going to work at the ward level, we cannot ensure quality at the ward level.

There must be a defined process for the involvement of the state even at this level to be able to take up some of these roles including financing.